British Journal of Sports Medicine

Whose pain is it anyway?

03-01-2020 – Waller, B.

My 9-year-old daughter woke up the morning after a long day of gymnastics training and complained that her muscle hurts. ‘I need a pill to stop the pain, NOW daddy’. Right, how do I deal with this one? Should I break out the pain education metaphors? Or give her a massage? Go for some contrast baths? I decided that the appropriate referral was a joint trip to the bakery. Over Finnish Pulla (cardamom sweet bread), we discussed that she had delayed-onset muscle soreness (DOMS), which is transient and not dangerous. During our cake-fuelled discussion, my daughter told me she had linked the use of ibuprofen for reducing a fever with helping her through the discomfort of well-earned DOMS. Rather than ‘endure’ the discomfort, she wanted a quick solution. If my 9-year-old daughter can make that connection, it is not difficult for others. Unfortunately, there is still excessive prophylactic use…

What proportion of athletes sustained an injury during a prospective study? Censored observations matter

03-01-2020 – Jungmalm, J., Bertelsen, M. L., Nielsen, R. O.


Introduction A common question in sports injury research is ‘what proportion of athletes sustained an injury over a certain time period?’. In cross-sectional studies, where data are collected at a single point in time, the prevalence proportion is simply the number of injured athletes divided by the total sample. In prospective cohort studies, caution is needed as the injury incidence proportion (proportion of newly injured athletes during the observation period) is likely to be underestimated by simply using the approach that is valid for cross-sectional studies. As a part of the BJSM methods matter series,1 we here compare the analytical approaches for cross-sectional studies and prospective cohort studies (ie, without censoring and with censoring, respectively) to help the reader accurately estimate incidence proportion in prospective studies. Cumulative incidence proportion (CIP) To describe the proportion of sports injuries occurring over a given time period, one…

Athlete autonomy, supportive interpersonal environments and clinicians duty of care; as leaders in sport and sports medicine, the onus is on us: the clinicians

03-01-2020 – Thornton, J. S.


Excellence for elite athletes demands painstaking attention to detail to all aspects of health, well-being and performance. Researcher and Olympic Taekwondo Gold Medalist Lauren Burns and coauthors1 use the power of the athlete story to argue strongly and convincingly that central to achieving excellence is durable interpersonal support. ‘If we look at an athlete as a whole person, there is a fundamental duty of care to ensure they are supported to become their best, most resilient self, both on and off the field. Athletes therefore need to be encouraged to seek interpersonal support that evolves as they move along their development pathway’. These sentences, both important, appear sequentially; but I will make one distinction—the onus to create a supportive environment should not rest primarily on athletes. Where then does the duty of care lie? According to Fisher et al’s heuristic model,2 the power differential in…

Soft-tissue injuries simply need PEACE and LOVE

03-01-2020 – Dubois, B., Esculier, J.-F.


Rehabilitation of soft-tissue injuries can be complex. Over the years, acronyms guiding their management have evolved from ICE to RICE, then on to PRICE and POLICE.1 Although widely known, these previous acronyms focus on acute management, unfortunately ignoring subacute and chronic stages of tissue healing. Our contemporary acronyms encompass the rehabilitation continuum from immediate care (PEACE) to subsequent management (LOVE). PEACE and LOVE (figure 1) outline the importance of educating patients and addressing psychosocial factors to enhance recovery. While anti-inflammatories show benefits on pain and function, our acronyms flag their potential harmful effects on optimal tissue repair. We suggest that they may not be included in the standard management of soft-tissue injuries. Immediately after injury, do no harm and let PEACE guide your approach.
P for protect Unload or restrict movement for 1–3 days to minimise bleeding, prevent distension of injured fibres and reduce…

Antioxidants for preventing and reducing muscle soreness after exercise: a Cochrane systematic review

03-01-2020 – Ranchordas, M. K., Rogerson, D., Soltani, H., Costello, J. T.

To determine whether antioxidant supplements and antioxidant-enriched foods can prevent or reduce delayed-onset muscle soreness after exercise.
We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, SPORTDiscus, trial registers, reference lists of articles and conference proceedings up to February 2017.
In total, 50 studies were included in this review which included a total of 1089 participants (961 were male and 128 were female) with an age range of 16–55 years. All studies used an antioxidant dosage higher than the recommended daily amount. The majority of trials (47) had design features that carried a high risk of bias due to selective reporting and poorly described allocation concealment, potentially limiting the reliability of their findings. We rescaled to a 0–10 cm scale in order to quantify the actual difference between groups and we found that the 95% CIs for all five follow-up times were all well below the minimal important difference of 1.4 cm: up to 6 hours (MD –0.52, 95% CI –0.95 to –0.08); at 24 hours (MD –0.17, 95% CI –0.42 to 0.07); at 48 hours (mean difference (MD) –0.41, 95% CI –0.69 to –0.12); at 72 hours (MD –0.29, 95% CI –0.59 to 0.02); and at 96 hours (MD –0.03, 95% CI –0.43 to 0.37). Thus, the effect sizes suggesting less muscle soreness with antioxidant supplementation were very unlikely to equate to meaningful or important differences in practice.
There is moderate to low-quality evidence that high-dose antioxidant supplementation does not result in a clinically relevant reduction of muscle soreness after exercise of up to 6 hours or at 24, 48, 72 and 96 hours after exercise. There is no evidence available on subjective recovery and only limited evidence on the adverse effects of taking antioxidant supplements.

What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: systematic review

03-01-2020 – Lin, I., Wiles, L., Waller, R., Goucke, R., Nagree, Y., Gibberd, M., Straker, L., Maher, C. G., OSullivan, P. P. B.

To identify common recommendations for high-quality care for the most common musculoskeletal (MSK) pain sites encountered by clinicians in emergency and primary care (spinal (lumbar, thoracic and cervical), hip/knee (including osteoarthritis OA and shoulder) from contemporary, high-quality clinical practice guidelines (CPGs).
Systematic review, critical appraisal and narrative synthesis of MSK pain CPG recommendations.
Eligibility criteria
Included MSK pain CPGs were written in English, rated as high quality, published from 2011, focused on adults and described development processes. Excluded CPGs were for: traumatic MSK pain, single modalities (eg, surgery), traditional healing/medicine, specific disease processes (eg, inflammatory arthropathies) or those that required payment.
Data sources
Four scientific databases (MEDLINE, Embase, CINAHL and Physiotherapy Evidence Database) and four guideline repositories.
Results6232 records were identified, 44 CPGs were appraised and 11 were rated as high quality (low back pain: 4, OA: 4, neck: 2 and shoulder: 1). We identified 11 recommendations for MSK pain care: ensure care is patient centred, screen for red flag conditions, assess psychosocial factors, use imaging selectively, undertake a physical examination, monitor patient progress, provide education/information, address physical activity/exercise, use manual therapy only as an adjunct to other treatments, offer high-quality non-surgical care prior to surgery and try to keep patients at work.
These 11 recommendations guide healthcare consumers, clinicians, researchers and policy makers to manage MSK pain. This should improve the quality of care of MSK pain.

How strong is the evidence that conservative treatment reduces pain and improves function in individuals with patellar tendinopathy? A systematic review of randomised controlled trials including GRADE recommendations

03-01-2020 – Mendonca, L. D. M., Leite, H. R., Zwerver, J., Henschke, N., Branco, G., Oliveira, V. C.

Journal Article, Review

To determine the effectiveness of conservative treatment (CT) on pain and function in patients with patellar tendinopathy (PT) compared with minimal intervention (MI) or other invasive intervention, or in addition to decline eccentric squat.
Searches were performed in MEDLINE, Embase, Cochrane, PEDro, SPORTDiscus, CINAHL and AMED databases. All randomised trials that evaluated CT (any intervention not involving invasive procedures or medication) in individuals with PT were included. Two reviewers screened studies, extracted data and assessed risk of bias of all included studies. Where suitable, meta-analyses were conducted; we assessed certainty of the evidence using GRADE methodology.
When compared with MI, CT did not improve pain (weighted mean difference (WMD) –2.6, 95% CI –6.5 to 1.2) or function (WMD 1.8, 95% CI –2.4 to 6.1) in the short-term (up to 3 months) follow-up. When compared with invasive intervention, CT did not improve pain (WMD 0.7, 95% CI –0.1 to 1.4) or function (WMD –6.6, 95% CI –13.3 to 0.2) in the short-term follow-up. No overall effects were found for combined CT (when a conservative intervention was added to decline eccentric squat) on pain (WMD –0.5, 95% CI –1.4 to 0.4) or function (WMD –2.3, 95 % –9.1 to 4.6) at short-term follow-up. Single studies showed an effect on pain with iontophoresis at short-term follow-up (d = 2.42) or dry needling at medium/long-term follow-up (d = 1.17) and function with exercise intervention at medium/long-term follow-up (over 3 months) (d = 0.83).
Our estimates of treatment effect have only low to very low certainty evidence to support them. This field of sports medicine/sports physiotherapy urgently needs larger, high-quality studies with pain and function among the potential primary outcomes.

Concussed athletes walk slower than non-concussed athletes during cognitive-motor dual-task assessments but not during single-task assessments 2 months after sports concussion: a systematic review and meta-analysis using individual participant data

03-01-2020 – Büttner, F., Howell, D. R., Ardern, C. L., Doherty, C., Blake, C., Ryan, J., Catena, R., Chou, L.-S., Fino, P., Rochefort, C., Sveistrup, H., Parker, T., Delahunt, E.

Journal Article, Review

To determine whether individuals who sustained a sports concussion would exhibit persistent impairments in gait and quiet standing compared to non-injured controls during a dual-task assessment .
Systematic review and meta-analysis using individual participant data (IPD).
Data sources
The search strategy was applied across seven electronic bibliographic and grey literature databases: MEDLINE, EMBASE, CINAHL, Sport
INFO, Psyc
ARTICLES and Web of Science, from database inception until June 2017.
Eligibility criteria for study selection
Studies were included if; individuals with a sports concussion and non-injured controls were included as participants; a steady-state walking or static postural balance task was used as the primary motor task; dual-task performance was assessed with the addition of a secondary cognitive task; spatiotemporal, kinematic or kinetic outcome variables were reported, and; included studies comprised an observational study design with case–control matching.
Data extraction and synthesis
Our review is reported in line with the Preferred Reporting Items for Systematic review and Meta-Analyses-IPD Statement. We implemented the Risk of Bias Assessment tool for Non-randomised Studies to undertake an outcome-level risk of bias assessment using a domain-based tool. Study-level data were synthesised in one of three tiers depending on the availability and quality of data: (1) homogeneous IPD; (2) heterogeneous IPD and (3) aggregate data for inclusion in a descriptive synthesis. IPD were aggregated using a ‘one-stage’, random-effects model.
Results26 studies were included. IPD were available for 20 included studies. Consistently high and unclear risk of bias was identified for selection, detection, attrition, and reporting biases across studies. Individuals with a recent sports concussion walked with slower average walking speed (2=51.7; df=4; p<0.001; mean difference=0.06 m/s; 95% CI: 0.004 to 0.11) and greater frontal plane centre of mass displacement (2=10.3; df=4; p=0.036; mean difference –0.0039 m; 95% CI: –0.0075 to –0.0004) than controls when evaluated using a dual-task assessment up to 2 months following concussion.
Our IPD evidence synthesis identifies that, when evaluated using a dual-task assessment, individuals who had incurred a sports concussion exhibited impairments in gait that persisted beyond reported standard clinical recovery timelines of 7–10 days. Dual-task assessment (with motion capture) may be a useful clinical assessment to evaluate recovery after sports concussion.
Protocol pre-registration
This systematic review was prospectively registered in PROSPERO CRD42017064861.

Return to play and risk of repeat concussion in collegiate football players: comparative analysis from the NCAA Concussion Study (1999-2001) and CARE Consortium (2014-2017)

03-01-2020 – McCrea, M., Broglio, S., McAllister, T., Zhou, W., Zhao, S., Katz, B., Kudela, M., Harezlak, J., Nelson, L., Meier, T., Marshall, S. W., Guskiewicz, K. M., On behalf of CARE Consortium Investigators

Journal Article

We compared data from the National Collegiate Athletic Association (NCAA) Concussion Study (1999–2001) and the NCAA-Department of Defense Concussion Assessment, Research and Education (CARE) Consortium (2014–2017) to examine how clinical management, return to play (RTP) and risk of repeat concussion in collegiate football players have changed over the past 15 years.
We analysed data on reported duration of symptoms, symptom-free waiting period (SFWP), RTP and occurrence of within-season repeat concussion in collegiate football players with diagnosed concussion from the NCAA Study (n=184) and CARE (n=701).
CARE athletes had significantly longer symptom duration (CARE median=5.92 days, IQR=3.02–9.98 days; NCAA median=2.00 days, IQR=1.00–4.00 days), SFWP (CARE median=6.00 days, IQR=3.49–9.00 days; NCAA median=0.98 days, IQR=0.00–4.00 days) and RTP (CARE median=12.23 days, IQR=8.04–18.92 days; NCAA median=3.00 days, IQR=1.00–8.00 days) than NCAA Study athletes (all p<0.0001). In CARE, there was only one case of repeat concussion within 10 days of initial injury (3.7% of within-season repeat concussions), whereas 92% of repeat concussions occurred within 10 days in the NCAA Study (p<0.001). The average interval between first and repeat concussion in CARE was 56.41 days, compared with 5.59 days in the NCAA Study (M difference=50.82 days; 95% CI 38.37 to 63.27; p<0.0001).
Our findings indicate that concussion in collegiate football is managed more conservatively than 15 years ago. These changes in clinical management appear to have reduced the risk of repetitive concussion during the critical period of cerebral vulnerability after sport-related concussion (SRC). These data support international guidelines recommending additional time for brain recovery before athletes RTP after SRC.

Modulation of cortical and subcortical brain areas at low and high exercise intensities

03-01-2020 – Fontes, E. B., Bortolotti, H., Grandjean da Costa, K., Machado de Campos, B., Castanho, G. K., Hohl, R., Noakes, T., Min, L. L.

Journal Article

The brain plays a key role in the perceptual regulation of exercise, yet neuroimaging techniques have only demonstrated superficial brain areas responses during exercise, and little is known about the modulation of the deeper brain areas at different intensities.
Using a specially designed functional MRI (f
MRI) cycling ergometer, we have determined the sequence in which the cortical and subcortical brain regions are modulated at low and high ratings perceived exertion (RPE) during an incremental exercise protocol.
Additional to the activation of the classical motor control regions (motor, somatosensory, premotor and supplementary motor cortices and cerebellum), we found the activation of the regions associated with autonomic regulation (ie, insular cortex) (ie, positive blood-oxygen-level-dependent (BOLD) signal) during exercise. Also, we showed reduced activation (negative BOLD signal) of cognitive-related areas (prefrontal cortex), an effect that increased during exercise at a higher perceived intensity (RPE 13–17 on Borg Scale). The motor cortex remained active throughout the exercise protocol whereas the cerebellum was activated only at low intensity (RPE 6–12), not at high intensity (RPE 13–17).
These findings describe the sequence in which different brain areas become activated or deactivated during exercise of increasing intensity, including subcortical areas measured with f
MRI analysis.

“Infographic. Progressing rehabilitation after injury: consider the control-chaos continuum”

03-01-2020 – Taberner, M., Allen, T., Cohen, D. D.

Journal Article

Return to sport (RTS) is a dynamic process, during which practitioners must balance the risk that early reintegration to training/match-play increases reinjury risk with the benefit to the team of having key players available.1 Medical and performance staff must work together to formulate a plan considering the individual, the specifics of the injury, tissue healing time and potential risk factors for reinjury. A key element of this plan is the management and prescription of external running loads using global positioning systems (GPS) to return players to previous levels of chronic load prior to injury, relatively quickly and safely.2 3 Alongside the quantitative elements of load, practitioners should also consider the qualitative nature of movement in competition that is, highly variable, spontaneous and unanticipated movements (‘chaos’), reflecting the unpredictable nature of sport. During the early stages of rehabilitation, however, control should be maintained using…

Infographic. Therapeutic exercise relieves pain and does not harm knee cartilage nor trigger inflammation

03-01-2020 – Bricca, A., Roos, E. M., Juhl, C. B., Skou, S. T., Silva, D. O., Barton, C. J.

Journal Article

Exercise and cartilage health: a common belief and evidence from randomised controlled trials (RCTs) in people at risk of, or with knee osteoarthritis (OA) OA is a leading cause of disability worldwide and associated with pain, impaired mobility and quality of life.1 Physical activity, including therapeutic exercise, patient education and weight control are recommended in key OA treatment guidelines.2 Nevertheless, the belief that therapeutic exercise may harm knee joint cartilage remains common among people with knee OA, and health professionals treating the condition, creating a prevailing barrier to implementing evidence-based care.3–5 The current discord between evidence and persistent beliefs highlights the need for better education. Providing a clear and engaging summary of the evidence to communicate the positive impact of therapeutic exercise and physical activity on the knee joint is crucial to encourage greater acceptance of, and participation…

Infographic. Tramadol: should it be banned in athletes while competing, particularly in road cycling?

03-01-2020 – Baltazar-Martins, J. G., Plata, M. d. M., Munoz-Guerra, J., Munoz, G., Carreras, D., Del Coso, J.

Journal Article

Tramadol is a synthetic opioid widely used for the management of pain in sport setting.1 Tramadol is considered an effective substance to reduce acute and chronic pain because it acts by binding to the μ-opioid receptor to induce analgesia and sedation. However, tramadol also inhibits serotonin and norepinephrine reuptake and thus, it might play a role in the regulation of mood. In the past years, tramadol has caught attention of media and antidoping authorities because this substance might be the subject of abuse in some sports, notably cycling.2 WADA determined that the use of some narcotics are prohibited in-competition but tramadol has never been banned, and it has not been included in the 2019 Prohibited List.3 Nevertheless, WADA has been monitoring the abuse of tramadol in all sports through the assessment of urine tramadol concentration in the samples obtained in-competition. WADA has established…

“How key intermediary organisations bridge the gap between injury prevention research and practice: novel insights”

03-01-2020 – Bekker, S.

What did I do? My research sought novel insight into how key intermediary organisations ‘bridge the gap’ between injury prevention research and its use in practice.1 The key intermediary organisations that contributed to this research were drawn from an existing partnership of a larger study—the National Guidance for Australian Football Partnerships and Safety project.2 The six organisations were: the Australian Football League, Victorian Health Promotion Foundation, New South Wales Sporting Injuries Committee, JLT Sport as a division of Jardine Lloyd Thompson Australia Pty Ltd, Sport and Recreation Victoria and Sports Medicine Australia. Why did I do it? I wanted to better understand the role that key intermediary organisations play in making injury prevention research knowledge more accessible and useful for end-users (including athletes, parents, coaches, club administrators and so on). How did I do it? First, I theorised about the gap…

“The Dormouse: my story as a lightweight rower with overtraining syndrome”

03-01-2020 – Woodford, L.

Journal Article

Intensive demands of ROWING To be a successful high-performance lightweight rower, I required exceptional physical attributes such as fitness and strength, together with high levels of dedication and resilience. However, when faced with frustrating setbacks such as injury and illness, like many athletes, the qualities that made me a champion became my own worst enemy. Vigorous specifically targeted training followed by sufficient recovery is essential to improve athletic performance. It is difficult to balance training and recovery and when you layer on the added constraint of a weight-limited sport like lightweight rowing, training becomes more complex. In my sport, lightweight rowing, women compete under 57 kg and men under 70 kg. Making weight was a real challenge for me at 57, so I maximised every opportunity to burn calories. That often meant choosing an active recovery session over a rest day, in my already challenging training schedule. …